Status Indicators - Wyoming Medicaid

  Wyoming Department of Health Updated 4/4/2012
Department of Healthcare Financing
OPPS Fee Schedule Legend

 

 

Outpatient Prospective Payment System (OPPS) Legend

 

 
 

Definitions

 

Description is the short procedure code description. Refer to the appropriate official
CPT or HCPCS coding manual for complete definitions to assure correct coding.

 

Ambulatory Payment Classification (APC) - The main payment method for the OPPS system
is the APC method which is used by Medicare. The Division of Health Care Financing has
adopted the IOCE with APC.

Composite APC - An APC fee calculation that takes into consideration the presence of multiple
procedures performed on the same date of service, and may discount the total payment due to
the procedures being performed in combination rather than in separate situations.

 

APC Relative Weight - The DHCF has adopted Medicare’s relative weights for each APC.
Each APC code is assigned a relative weight to determine how it will price for payment.

Conversion Factor - A conversion factor is a standard dollar amount that is used to translate
relative weights into payment. For current conversion factors review the APC fee schedule
available on the website. Medicaid has designated three (3) conversions for the following
facility types:
 

 General Acute Care Hospitals

 Children’s Hospitals

 Critical Access Hospitals 

 

Status Indicators
 

Status  Description   Comments 
Code  

1  Not Covered  Indicates a service that is not covered by Medicaid (e.g., 
a service that cannot be provided in an outpatient 
hospital setting or that is not a covered Medicaid 
benefit).  

2  Paid a percentage of charges  Paid by multiplying billed charges by a hospital‐specific 
cost‐to‐charge ratio.  

3  Other fee schedule   Indicates a service that is excluded from the APC‐based 
methodology, e.g., laboratory and screening 
mammographies. 

 

Status  Medicare Description Wyoming use of Status Indicators 
Code  

A  Services not Paid under OPPS; Paid  Not paid under OPPS.
under fee schedule or other payment 
system 

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  Wyoming Department of Health Updated 4/4/2012
Department of Healthcare Financing
OPPS Fee Schedule Legend

B  Non‐allowed item or service for OPPS  Not paid under OPPS. 

C  Inpatient procedure   Not paid under OPPS.

D  Discontinued Codes  Not Paid under any system

E  Non‐allowed item or Service  Not Paid under any outpatient system 

F  Corneal tissue acquisition; certain  Not paid under OPPS. Paid at reasonable cost  
CRNA services and hepatitis B 
vaccines  

G  Pass‐through drugs and biologicals Paid under OPPS; Separate APC payment includes pass‐
through amount.  

H  (1) Pass‐through device categories Paid under OPPS; (1) separate cost‐based pass‐through 

payment; (2) separate cost‐based non pass‐through 

(2) Therapeutic  payment  

Radiopharmaceuticals  

K  Non pass‐through drugs and  Paid under OPPS; separate APC payment  
biological 

L  Flu/PPV vaccines   Not paid under OPPS. Paid at reasonable cost  

M  Services that are only billable to  Not paid under OPPS
carriers and not to fiscal 
intermediaries 

N  Items and services packaged into APC  Paid under OPPS; Payment is packaged into payment for 

rates   other services. 

P  Partial Hospitalization Service Not Paid under OPPS

Q1  STVX‐Packaged codes subject to  Paid under OPPS; (1) Packaged APC payment if billed on 
separate payment under OPPS  the same date of service as a STVX procedure code; (2) 
payment criteria.  separate APC payment  

Q2  T packaged codes subject to separate  Paid under OPPS; (1) Packaged APC payment if billed on 

payment under OPPS Payment  the same date of service as a T procedure code; (2) 

criteria.  separate APC payment  

Q3  Codes that may be paid through a  Paid under OPPS; (1) Composite APC payment based on 

Composite APC  composite criteria; (2) Paid through a separate APC; (3) 

Payment is packaged into payment for other services  

R  Blood and Blood Products  Paid under OPPS; separate APC payment  

S  Significant procedure, not discounted  Paid under OPPS; separate APC payment  
when multiple  

T  Significant procedure, multiple  Paid under OPPS; separate APC payment  
reduction applies 

U  Brachytherapy Sources  Paid under OPPS; pays at % of Charges 

V  Clinic or emergency department visit  Paid under OPPS; separate APC payment  

X  Ancillary services   Paid under OPPS; separate APC payment  

Y  Non‐implantable durable medical  Not paid under OPPS
equipment (DME) 

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  Wyoming Department of Health Updated 4/4/2012
Department of Healthcare Financing
OPPS Fee Schedule Legend

 

 

Fees

 

Fees are affected by modifiers, units, discount formulas, and revenue codes

Modifiers

Hospital Outpatient Services Modifiers – the below table shows modifiers that are allowed under
OPPS

  Level II (HCPCS) Modifiers 

Level I (CPT) Modifiers   91  BL  CA EA FA GA J1 KG LC Q0  P1  RC  TA
25  50  63  73 
27  52    74      CR EB FB GG J2 KK LD Q1  P2  RT  T1
33  58    76 
  59    77     EC FC GH J3 KL LT   P3    T2
      78 
      79     E1 F1 GR KT   P4    T3
    
        E2 F2 GS KU   P5    T4
    
        E3 F3 GZ KV   P6    T5
    
        E4 F4 KW       T6
    
   F5 KY       T7

   F6       T8

   F7       T9

   F8    

   F9    

      

 
 

Discount Formulas

Medicaid will discount payment for certain multiple, bilateral or discontinued procedures as described

below for type “T” and non-type “T” procedures. Type “T” procedures are procedure codes assigned a

status indicator of “T”.

 

Discounting for Type “T” Procedures (Significant Procedures Subject to Discounting)

• Multiple procedures – Medicaid will discount payment for certain procedures when a
hospital performs two or more type “T” procedures on the same day for the same
patient. The “T” procedure with the highest relative weight will not be discounted.
The remaining “T” procedures will be multiple procedure discounted. If any of the
following modifiers are present on the claim line item, the procedure will not be
subject to multiple procedure discounting:

 

 76 – Repeat procedure by same physician
 77 – Repeat procedure by another physician
 78 – Return to the operating room for a related procedure during the

postoperative period
 79 – Unrelated procedure or service by the same physician during

the postoperative period.

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  Wyoming Department of Health Updated 4/4/2012
Department of Healthcare Financing
OPPS Fee Schedule Legend

 

• Bilateral procedures – The first type “T” bilateral procedure, indicated by modifier 50

(bilateral procedure) will not be discounted. The remaining “T” bilateral procedures

will be bilateral procedure discounted. The discounting factor for bilateral

procedures is the same as the discounting factor for multiple type “T” procedures.

 

• Discontinued procedures – Medicaid will discount type “T” procedures that a hospital

discontinues before completion, indicated by modifier 52 (reduced services) or 73

(discontinued outpatient procedure prior to anesthesia administration). The “T”

discontinued procedure with the highest relative weight will be discounted 50 percent

of the payment rate. The remaining “T” discontinued procedures will be discontinued

procedure discounted. Any applicable offset will be applied prior to selecting the type

“T” procedure with the highest payment amount. If both offset and terminated

procedure discount apply, the offset will be applied first before the terminated

procedure discount.

 

 
 

Discounting for Non-Type “T” Procedures

 

• Bilateral procedures – The first non-type “T” bilateral procedure, indicated by modifier

50 (bilateral procedure) will not be discounted. The remaining non- type “T” bilateral

procedures will be bilateral procedure discounted. The discounting factor for bilateral

procedures is the same as the discounting

factor for multiple type “T” procedures.

 

• Discontinued procedures – Medicaid will discount non-type “T” procedures that a

hospital discontinues before completion, indicated by modifier 52 (reduced services)

or 73 (discontinued outpatient procedure prior to anesthesia administration). Modifier

52 or 73 on a non-type “T” procedure line will

result in a 50 percent discount applied to that line.

 

Discount Formulas   Discount Factors  

1 1.0   1.0  

2 ( 1.0 + D(U - 1) ) / U   1 Discount factors indicated are

3 T/U   0.5 when the number of units is

4 (1 + D) / U   1.5 equal to 1 (one)
5D   0.5
 

6 TD / U   0.25  

7 D (1 + D) / U   0.75  

8 1.5   1.5  

        

D Discounting fraction (currently 0.5)  
 
U Number of units   

T Terminated procedure discount (currently 0.5)  

 

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